ATLANTA-How teens perceive themselves when they look into the mirror can be a more significant factor in their risk of suicide than their actual body weight.

Action Points

Physicians might want to consider asking young patients at risk for mental health problems how they feel about their body weight. This study found a negative body image was associated with an increased risk for suicidal behavior.

Fifteen percent of all U.S. children are overweight or obese, according to the CDC. Encourage children struggling with excess weight to eat a balanced diet and exercise regularly.

ATLANTA, June 8-How teens perceive themselves when they look into the mirror can be a more significant factor in their risk of suicide than the number on the bathroom scale.

So said a study published in the June issue of Archives of Pediatric Adolescent Medicine, which found adolescents' personal perceptions of being too thin or too fat was associated with heightened risks for suicidal thoughts and attempts. The perception was often divorced from actual body mass index measurements.

The researchers, led by Danice K. Eaton, Ph.D., of the CDC said their study does not establish a causal relationship between suicidal risk and body image.

"Perceived weight alone does not explain why a person exhibits suicidal behavior," Dr. Eaton and colleagues wrote. "However, the presence of extreme-weight perception may serve as a warning for an increased suicide risk."

Dr. Eaton's study used data from the national 2001 Youth Risk Behavior Survey, which included 13,601 students in grades nine through 12. More than two-thirds of the student sample were white, 13% were black, and 12% were Hispanic. Fifty-one percent of the students were female.

Body mass index measurements were based on self-reported figures of height and weight. The students were asked whether they had experienced suicidal thoughts or had attempted suicide in the previous 12 months. They were also asked whether they had fasted during the previous 24 hours to lose weight.

The teens then ranked their body image according to these categories: very underweight, slightly underweight, normal weight, slightly overweight and very overweight.

White teens on the polar ends of the spectrum appeared to be at the greatest risk for suicidal attempts. When compared with those who felt they were of normal weight, perceiving oneself as very underweight or very overweight was associated with a higher risk for suicide attempts, odds ratio, 3.04 [95% confidence interval, 1.40-6.58] and OR, 2.74 [95% CI, 1.21-6.23], respectively.

Perceiving oneself as being too skinny was a risk for suicidal attempts among blacks and Hispanics when compared with adolescents who viewed their weight as normal, odds ratio, 2.86 [95% CI, 1.10-7.45] and OR, 3.40 [95% CI, 1.54-7.51], respectively.

However, in contrast with the white teens, there were no negative psychological associations with perceptions of being overweight among blacks and Hispanics.

Even viewing oneself as slightly underweight or slightly overweight was linked to suicidal thinking in the study group, OR, 1.36 [95% CI, 1.03-1.79] and OR, 1.33 [95% CI, 1.12-1.58], respectively, when compared with those who saw their weight as normal.

Body mass index was associated significantly with suicidal thoughts. However, the researchers said how students perceive their bodies was more important than their actual weight. "Regardless of body mass index, extreme perceptions of weight appear to be significant risk factors for suicidal behavior," although important racial differences do exist, they concluded.

"We need to understand how students perceptions are formed and what the mechanism is," Dr. Eaton said in an interview. "Why perceiving oneself as anything other than normal weight is associated with negative mental health outcomes." The data did not look at whether the students' perceptions of themselves were accurate, she said.

The study comes during an explosion of childhood obesity, an issue that has now risen to the top of the federal government's 'To Do' list. The rate of obese children has tripled from 5% in 1980 to 15% in 2000, according to the CDC.

Dr. Eaton also acknowledged that self-reported height and weight measurements from teens with skewed body perceptions might have affected the study results. "Their self-report of their height and weight was probably influenced by their perceptions so that could've watered down the effect," she said.

Nevertheless, perceptions appear to play a critical role in teens' mental health. "Because nearly one half of students perceived themselves as either slightly or very overweight or slightly or very underweight," Dr. Eaton and colleagues said, "these results suggest that a sizeable proportion of students may be at increased risk for suicide ideation."

In an accompanying editorial, Alain Joffe, M.D., M.P.H. from Johns Hopkins in Baltimore questioned what was influencing these high school students' self-images.

"What is the explanation for the fact that almost 72% of the females in [this] study had a normal body mass index, yet approximately 12% and 37% considered themselves underweight and overweight, respectively?" Dr. Joffe wrote. "Do they receive subtle cues or not so subtle cues from peers and parents" or the media, he asked.

Dr. Joffe concluded, "Recognizing the importance of perception is useful in a clinical perspective."

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